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BCPS Exam > Critical Care: Pain and Agitation > Flashcards

Critical Care: Pain and Agitation Flashcards

1
Q

List 6 nonpharm strategies to improve patient comfort

A
  1. lighting
  2. music
  3. massage
  4. verbal reassurance
  5. avoidance of sleep deprivation
  6. patient positioning based on patient preferences
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2
Q

What two scales are preferred to measure pain in critical care patients who cannot communicate?

A
  1. Behavioral Pain scale (BPS)

3. Critical-Care Pain Observation Tool (CPOT)

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3
Q

The total BPS score can range from ___ (no pain) to ___ (maximum pain). A score of _ or higher is generally considered to reflect unacceptable pain.

A
  1. No pain: 3
  2. Maximum pain: 12
  3. Unacceptable pain: 6
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4
Q

The total CPOT score can range from __ to ___. A score of __ or higher is generally considered to reflect unacceptable pain.

A
  1. 0 to 8

2. A score of 3 or higher is generally considered to reflect unacceptable pain

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5
Q

In patients who are receiving neuromuscular blockade, _____ indicate further assessment of pain is necessary

A

Vital signs (elevated HR or BP)

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6
Q

What two scales are preferred to measure sedation?

A
  1. Richmond agitation-sedation scale (RASS)

2. Sedation-Agitation Scale (SAS)

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7
Q

Goal sedation scores should be _____, but generally a SAS score of ___ or a RASS score of ___ is recommended

A
  1. Scores should be individualized for each patient
  2. SAS: 3-4 (sedated - calm and cooperative)
  3. RASS of 0 to -1 (alert and calm - drowsy)
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8
Q

Describe analgosedation in treatment of agitation

A
  1. Pain and discomfort are primary causes of agitation

2. Treat pain first and add a sedative if needed

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9
Q

To minimize discomfort, use ____ and _____ before potentially painful procedures

A
  1. Bolus dose analgesics

2. Nonpharmacologic interventions

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10
Q

In critical care, _____ are considered first line for the treatment of nonneuropathic pain.

A

Opioids

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11
Q

In critical care, ____ and ____ are considered first line for neuropathic pain

A
  1. Gabapentin

2. Carbamazepine

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12
Q

Describe multimodal analgesia

A
  1. Nonopioid analgesics (e.g. acetaminophen, ketamine) can be used in cojunction with opioids
  2. To optimize pain control and to avoid dose-related adverse effects
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13
Q

NSAIDs are usually avoided in critical care because of the risk of ______ and _____

A
  1. Risk of bleeding

2. Kidney injury

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14
Q

In mechanically ventiled patients, which type of sedative is preferred to improve clinical outcomes?

A

Nonbenzodiazepine

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15
Q

Explain the relationship between targeting light sedation and improving patient outcomes?

A
  1. Light sedation is needed for evaluating pain and delirium

2. and for early patient mobility

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16
Q

How should analgesics and sedative dosing be guided?

A

To achieve pain and sedation goals

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17
Q

List three dosing strategies for analgosedation

A
  1. As needed
  2. Intermittent dosing
  3. Bolus dose with continuous infusion
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18
Q

In a patient receiving a continuous infusion plus bolus strategy, what is the preferred strategy for alleviating pain or agitation? Why?

A
  1. Increase bolus dose before or instead of increasing the infusion rate
  2. Bolus has a faster onset
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19
Q

What two drugs are exceptions to bolus dosing strategies?

A

Propofol and dexmedetomidine which can cause hypotension and bradycardia

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20
Q

Use bolus dosing ____, such as before dressing changes

A

Proactively

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21
Q

List six potential benefits of schedule daily awakening

A
  1. Assess the patient’s neurologic function
  2. reevaluate lowest effective opioid or sedative dose
  3. Prevent drug accumulation and overdose
  4. Reduce time on ventilator (mixed evidence)
  5. Reduce mortality and ICU length of stay when combined with a spontaneous breathing trial
  6. Reduce symptoms of PTSD and post-ICU syndrome
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22
Q

How is scheduled daily awakening performed in the ICU?

A
  1. Interruption of continuous infusion opioid/sedatives
  2. Until patient is awake (SAS of 4 or RASS of 0)
  3. If the patient becomes agitated/discomfort/pain (e.g. SAS or 5 or RASS of 1), reinitiate, ideally at a reduced dose.
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23
Q

List three common opioid analgesics used in critical care

A
  1. morphine
  2. fentanyl
  3. hydromorphoen
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24
Q

Rank the onset of Morphine, Fentanyl, and Hydromorphone, and state the minutes

A
  1. Fentanyl (1-2 minutes)
  2. Morphine (5-10 minutes)
  3. Hydromorphone (5-15 minutes)
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25
Q

Rank the duration of Morphine, Fentanyl, and Hydromorphone, and state the hours

A
  1. Fentanyl (1-5 hours)
  2. Morphine (2-4 hours)
  3. Hydromorphone (2-6 hours)
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26
Q

Rank the half-life of Morphine, Fentanyl, and Hydromorphone, and state the hours

A
  1. Hydromorphone (2-3 hours)
  2. Fenatnyl (2-4 hours)
  3. Morphine (3-4 hours)
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27
Q

For each Morphine, Fentanyl, and Hydromorphone, are they prolonged in renal failure?

A
  1. Morphine: Yes
  2. Fentanyl: No
  3. Hydromorphone: No
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28
Q

Morphine, Fentanyl, and Hydromorphone, are they prolonged in hepatic failure?

A
  1. Morphine: Yes
  2. Fenatnyl: yes
  3. Hydromorphone: yes
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29
Q

Morphine, Fentanyl, and Hydromorphone, do they have active metabolites?

A
  1. Morphine: Yes
  2. Fentanyl: No
  3. Hydromorphone: No
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30
Q

List four critical care adverse effects of opioids (not all)

A
  1. Hypotension
  2. Flushing
  3. Bronchospasm
  4. Constipation
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31
Q

Morphine, Fentanyl, and Hydromorphone, do they cause hypotension?

A
  1. Morphine: Yes
  2. Fentanyl: No
  3. Hydromorphone: Yes
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32
Q

Morphine, Fentanyl, and Hydromorphone, do they cause flushing?

A
  1. Morphine: Yes
  2. Fentanyl: No
  3. Hydromorphone: Yes
33
Q

Morphine, Fentanyl, and Hydromorphone, do they cause bronchospasm?

A
  1. Morphine: Yes
  2. Fentanyl: no
  3. Bronchospasm: no
34
Q

Morphine, Fentanyl, and Hydromorphone, do they cause constipation?

A
  1. Morphine: Yes
  2. Fentanyl: Yes
  3. Hydromorphone: Yes
35
Q

What CC adverse effects does morphine cause?

A
  1. Hypotension
  2. Flushing
  3. Bronchospasm
  4. Constipation
36
Q

What CC adverse effects does fentanyl cause?

A
  1. Constipation
37
Q

WHat CC adverse effects does hydromorphine cause?

A
  1. Hypotension
  2. Flushing
  3. Constipation
    ((NOT bronchospasm))
38
Q

List three possible critical care adverse outcomes of benzodiazepines

A
  1. Prolonged duration of mechanical ventilation
  2. Increased ICU length of stay
  3. Development of delirium
39
Q

List three non-benzo sedatives

A
  1. Propofol
  2. Dexmedetomidine
  3. Ketamine
40
Q

List three common CC benzodiazepines

A
  1. diazepam
  2. lorazepam
  3. midazolam
41
Q

Diazepam, lorazepam, midazolam, rank the onset and state minutes

A
  1. Midazolam = diazepam (2-5 minutes)

3. Lorazepam (15-20 minutes)

42
Q

Diazepam, lorazepam, midazolam, rank the duration of effect (hours)

A
  1. Midazolam (1-2 hours)
  2. Diazepam (2-4 hours)
  3. Lorazepam (4-6 hours)
43
Q

Diazepam, lorazepam, midazolam, rank the elimination half-life

A
  1. Midazolam (1-10 hours)
  2. Lorazepam (10-20 hours)
  3. Diazepam (24-120 hours)
44
Q

Diazepam, lorazepam, midazolam, do they have active metabolites?

A
  1. Diazepam: Yes
  2. Lorazepam: No
  3. Midazolam: Yes
45
Q

Diazepam, lorazepam, midazolam, prolonged in renal failure?

A
  1. Diazepam: Yes
  2. Lorazepam: No
  3. Midazolam: Yes
46
Q

Diazepam, lorazepam, midazolam, prolonged in hepatic failure?

A
  1. Diazepam: Yes
  2. Lorazepam: No
  3. Midazolam: Yes
47
Q

Diazepam, lorazepam, midazolam, CYP3A4 interactions?

A
  1. diazepam: Yes
  2. Lorazepam: No
  3. Midazolam: Yes
48
Q

List three important critical care adverse effects of benzodiazepines (not all)

A
  1. Hypotension
  2. Thrombophlebitis
  3. Propylene glycol toxicity
49
Q

Diazepam, lorazepam, midazolam, cause hypotension?

A
  1. Diazepam: Yes
  2. Lorazepam: No
  3. Midazolam: No
50
Q

Diazepam, lorazepam, midazolam, cause thrombophlebitis?

A
  1. Diazepam: Yes
  2. Lorazepam: Maybe
  3. Midazolam: No
51
Q

Diazepam, lorazepam, midazolam, cause propylgene glycol toxicity?

A
  1. Diazepam: No
  2. Thrombophlebitis: Yes
  3. Midazolam: No
52
Q

Describe intermittent dosing of lorazepam

A
  1. Lorazepam 1-4 mg every 2-6 hours
53
Q

Describe continuous infusion of lorazepam

A
  1. Start at 1 mg/hour and titrate to goal (e.g. RASS, SAS)

2. Total daily doses as low as 1 mg/kg can cause propylene glylcol toxicity

54
Q

How to monitor for propylene glycol toxicity with lorazepam?

A
  1. Osmolal gap greater than 10-12 mOsm/L
55
Q

Describe midazolam intermittent dosing

A

1-4 mg every 15 minutes to 1 hour

56
Q

Describe midazolam continuous infusion

A

Start at 1 mg/hour and titrate to goal

57
Q

Prolonged infusions of midazolam may accumulate because of its ___ and ___, especially in patients with _____

A
  1. Greater lipophilicity
  2. Active metabolites
  3. Especially in patients with renal dysfunction
58
Q

What is the preferred BZD in severe hepatic dysfunction?

A

Lorazepam

59
Q

What is a useful role for midazolam? Why?

A
  1. Procedural sedation
  2. Dressing changes
  3. Rapid onset and short duration
60
Q

Propofol is more commonly used than BZD because of its _____, ___ and ____

A
  1. Shorter duration
  2. Easy titration
  3. Predictability
61
Q

In general, propofol is used in ___ because of its risk of ______

A
  1. Intubated patients

2. Respiratory depression

62
Q

Describe results of MIDEX study

A
  1. Dexmedetomidine is noninferior to midazolam in maintaining light to moderate sedation
  2. Dex reduced the duration of mechancial ventilation compared with midazolam
63
Q

Describe results of PRODEX

A
  1. Dexmedetomidine is noninferior to propofol in maintaining light to moderate sedation
  2. Dex was noninferior compared to propofol in duration of mechanical ventilation
64
Q

Describe onset and duration of propofol

A
  1. Onset: 1-2 minutes

2. Duration: 3-5 minutes

65
Q

Why are loading doses avoided with propofol?

A

Risk of hypotension

66
Q

Describe monitoring for propofol

A
  1. BP
  2. Triglycerides
  3. Adjust lipids/calories provided by nutrition support (1.1 kcal/mL)
  4. Propofol-related infusion syndrome
67
Q

List seven symptoms of propofol-related infusion syndrome

A
  1. Metabolic acidosis
  2. Cardiac failure
  3. Arrhythmias (e.g. bradycardia)
  4. Cardiac arrest
  5. Rhabdomyolysis
  6. Hyperkalemia
  7. Kidney failure
68
Q

What types of infusions of propofol pose greatest risk for propofol-related infusion syndrome

A

greater than 50 mcg/kg/minute, prolonged infusions

69
Q

Describe dosing of propofol

A
  1. Initiate at 5 mcg/kg/minute
  2. Titrate to acehive sedation goals
  3. Increment by 5 mcg/kg/minute every 5 minutes
  4. avoid greater than 50 mcg/kg/minute
70
Q

Describe respiratory depression risk of dexmedetomidine

A

No risk of respiratory depression

71
Q

Describe onset and duration of dexmedetomidine

A
  1. Onset: 5-15 miutes if bolus
  2. duration: (2 hour half life)
  3. Longer duration in patients with severe hepatic dysfunction
72
Q

When is a loading dose of dexmedetomidine used? WHen is it avoided and why?

A
  1. Loading dose is suggested in patients underoing surgery

2. It is not recommended for patients in the ICU because of bradycardia and hypotension.

73
Q

Describe monitoring of dexmedetomidine

A

Bradycardia, hypotension

74
Q

Describe dosing of dexmedetomidine

A
  1. Maintenace dose of 0.2 mcg/kg/hour is approved for a maximum of 24 hours.
  2. There is evidence showing safety and efficacy at doses up to 1.5 mcg/kg/hour, which is most commonly used.
75
Q

withdrawal symptoms from dexmedetomidine (e.g. ________, ____, ___) have occurred after prolonged use (what tiem period?)

A
  1. Nausea
  2. Vomiting
  3. Agitation
  4. 1 week
76
Q

Describe risk of respiratory depression with ketamine

A

No risk of respiratory depression

77
Q

Describe major adverse effects of ketamine

A
  1. Hypertension
  2. tachycardia
  3. Delirium
78
Q

Describe the risk of delirium with ketamine

A

There is a risk of emergence delirium when high doses are tapered off

BCPS Exam (34 decks)

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